Fitness University Questionnaire
Name: *
E-mail: *
Phone:
Service Requested:	One on One Group In Home Sport Specific Corporate
Health History
Do you have or have ever had:
High blood pressure?	Yes No
Cholesterol over 200?	Yes No
Heart Attack?	Yes No
Prop lapse, Angina, Mitro Valve?	Yes No
Stroke?	Yes No
Frequent episodes of dizziness or fainting?	Yes No
Vertigo?	Yes No
Are you taking any medications regularly?	Yes No
Orthopedic History
Have you ever had a problems exercise or nonexercise related with:
Head or Neck?	Yes No
Shoulder or Rotator Cuff?	Yes No
Arms, Elbows, Wrists, or Hands?	Yes No
Upper or Lower Back?	Yes No
Hip or Pelvis?	Yes No
Knees, Ankles, or Feet?	Yes No
Surgery within the last 2 years?	Yes No
Diet!
Are you a vegetarian/ Vegan?	Yes No
Do you have any food allergies?	Yes No
If yes, please explain: